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Hospital collaborative reduces readmissions by 11 percent

May 23, 2013

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A collaborative that includes 21 San Francisco Bay Area hospitals has reduced the number of discharged patients readmitted to local hospitals by 11 percent, which represents about 3,300 hospitalizations and saves an estimated $32 million in medical costs.

This is good news for patients and hospitals: patients aren’t returning to the hospital as frequently because they’re able to manage their health at home. And hospitals are saving on costs while also meeting the reduced-readmission goals that are part of healthcare reform. Hospitals failing to reduce readmissions could pay penalties such as reduced Medicare payments.

The Gordon and Betty Moore Foundation, started by the Intel founder and his wife, funded the Avoiding Readmission through Collaboration group and challenged them to reach the goal of a 30-percent reduction in 30-day and 90-day readmissions by the end of 2013. These indicators show that the collaboration is working to improve care at the critical time when patients are leaving the hospital.

“Improving the transition after a hospitalization is key to ensuring the best outcomes for the patient—something that is very important to Betty Moore, who started the foundation’s nursing initiative,” said Dr. Liz Malcolm, who serves as a program officer with the Moore Foundation’s Betty Irene Moore Nursing Initiative. “Patients and families need support, information and a seamless handoff to the next provider as they leave the hospital.”

Pat Teske, RN, MHA, is the implementation officer for the collaborative and said that one in five discharged Medicare patients (about 2 million people annually) return to a hospital within 30 days, as noted in the New England Journal of Medicine.

“Readmissions not only cost more than $17 billion annually, but also have a huge impact on patients,” Teske said. “Our success with reducing readmissions is a critical indicator that Bay Area hospitals are improving healthcare outcomes for thousands of patients.”

It’s easy for patients to feel overwhelmed when they leave the hospital. This point in time, known as transitional care, offers the promise of setting patients up to stay healthy outside the hospital and save medical costs, if it’s managed effectively. Hospital staff in the Avoiding Readmissions through Collaboration group recognize these approaches as ones that make a difference in transitional care and reducing readmissions—and ones that other hospitals could replicate.

Stay focused on improvement: An improvement adviser, Teske, worked with hospitals in the collaborative to help them use their own data about unnecessary readmissions to improve their care for patients during transitions.

Follow patient-focused care models: Hospitals learned how to implement care practices shown to improve transitions, such as helping patients understand how to manage medications after discharge and learn what to do if symptoms worsen.

Improve communication: Hospitals formed partnerships with primary care doctors, skilled nursing facilities and others to improve communication and help patients get the care they need after discharge.

The Moore Foundation has been working to help hospitals improve transitions of care for San Francisco Bay Area patients since 2005. Partners such as the University of California, San Francisco reduced 30-day readmissions for heart failure patients by 46 percent, which they accomplished by hiring a team of nurses to focus on transitional care needs. Chinese Hospital in San Francisco reduced readmissions for older heart failure patients by developing Chinese-language tools to help patients understand how to manage their condition after discharge. They also called patients at home after discharge.

“The 11-percent reduction marks a difference in the lives of more than 3,000 patients,” Malcolm said. “Continued work in these hospitals, and — most importantly — continued collaboration can lead to more improvements for patients and cost savings for hospitals.”

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The Gordon and Betty Moore Foundation is committed to making a meaningful difference in environmental conservation, patient care and scientific research. Intel co-founder Gordon and his wife Betty established the foundation in 2000 to create a positive, lasting impact around the world and at home in the San Francisco Bay Area. The Patient Care Program focuses on eliminating preventable harm by redesigning healthcare and engaging patients and families. The Avoid Readmissions through Collaboration effort is funded through the Patient Care Program’s Betty Irene Moore Nursing Initiative. For more information visit Moore.org or follow @MoorePatient.